An inquest in Preston heard Mrs Tooze-Froggatt had been taking the contraceptive pill and had a family history of thrombosis. Yet neither was acted on by clinicians at the BMI Lancaster Hospital.

Dr Adeley announced he would be writing a Regulation 28 Report to hospital bosses and the Care Quality Commission outlining his concerns about “a number of issues” over the death.

“I write one or maybe two of these a year,” he said. “I often think carefully whether they are required or not. But this case required much less thought than most.”

Mrs Tooze-Froggatt, of Coolidge Avenue, Lancaster, died four days after a cartilage repair. A post mortem found multiple blood clots in her lungs. The cause of death was recorded as “pulmonary embolism and deep vein thrombosis contributed to by a right knee cartilage repair and oral contraceptive pill.”

It was also recommended that patients at increased risk of DVT – Mrs Tooze-Froggatt’s father died of a pulmonary embolism – should be offered preventative treatment. But neither happened before the surgery in May 2015.

And because her surgery came on the day before a Bank Holiday weekend, no follow-up call had been made by the hospital to check how she was.

Dr Adeley said the consultant in charge of Mrs Tooze-Froggatt’s case had not known she was taking the pill and he had not asked any questions about family history.

“These are basic errors that one would expect any doctor to ascertain either from reading the records or asking the patient,” he said.

His conclusion was that Mrs Tooze-Froggatt had died “following multiple missed opportunities to treat her high risk of venous thromboembolism that would have saved her life”.